The public hospital system

When you finish this chapter you should be able to: * understand how the public hospital system is funded by the Federal, state and territory governments * appreciate some of the major funding issues facing public hospitals in Australia * have a beginning understandingof casemix Deagnosis Related Groups (DRGs) * have insight into the position of the various interest groups funding public hospitals in Australia.

Modelling the flow of congestive heart failure patients through a hospital system

The number of hospital admissions in England due to heart failure is projected to increase by over 50% during the next 25 years. This will incur greater pressures on hospital managers to allocate resources in an effective manner. A reliable indicator for measuring the quantity of resources consumed by hospital patients is their length of stay (LOS) in care. This paper proposes modelling the length of time heart failure patients spend in hospital using a special type of Markov model, where the flow of patients through hospital can be thought of as consisting of three stages of care—short-, medium- and longer-term care. If it is assumed that new admissions into the ward are replacements for discharges, such a model may be used to investigate the case-mix of patients in hospital and the expected patient turnover during some specified period of time. An example is illustrated by considering hospital admissions to a Belfast hospital in Northern Ireland, between 2000 and 2004.

TRARESA: a tissue microarray-based hospital system for biomarker validation and discovery

Formalin fixed and paraffin embedded tissue (FFPE) collections in pathology departments are the largest resource for retrospective biomedical research studies. Based on the literature analysis of FFPE related research, as well as our own technical validation, we present the Translational Research Arrays (TRARESA), a tissue microarray centred, hospital based, translational research conceptual framework for both validation and/or discovery of novel biomarkers. TRARESA incorporates the analysis of protein, DNA and RNA in the same samples, correlating with clinical and pathological parameters from each case, and allowing (a) the confirmation of new biomarkers, disease hypotheses and drug targets, and (b) the postulation of novel hypotheses on disease mechanisms and drug targets based on known biomarkers. While presenting TRARESA, we illustrate the use of such a comprehensive approach. The conceptualisation of the role of FFPE-based studies in translational research allows the utilisation of this commodity, and adds to the hypothesis-generating armamentarium of existing high-throughput technologies.

Prevalence and cost of musculoskeletal disorders: a population-based, public hospital system healthcare consumption approach.

Objective: To use a population-level, public-hospital approach to compare the prevalence and cost of musculoskeletal diseases (MSD) with other clinical specialties.

Methods: A healthcare utilization survey of 4 million individual records over 4 years, from all major public hospitals in the state of Victoria (estimated population 4.8 million residents in 2000/01) from 1997/98 to 2000/01. Main outcome measures were inpatient episodes of care, bed-days, and outpatient clinic encounters. MSD was defined as the combination of orthopedics and rheumatology.

Results: After obstetrics, MSD was the most frequent outpatient service, with orthopedics accounting for 9.9% of all visits in 2000/01. The proportion of MSD outpatient encounters (on average 11.6% of the total) was constant over the study period. Among 26 medical specialties, MSD had the sixth highest number of inpatient episodes (6.2% in 2000/01), following renal dialysis (14.6%), general surgery (8.2%), obstetrics (7.6%), gastroenterology (7.1%), and general medicine (6.7%). MSD was the fifth highest consumer of bed-days, occupying on average 7.7% of all beds per annum in the period 1997/98 to 2000/01, behind psychiatry (10.1%), respiratory medicine (8.5%), rehabilitation (8.3%), and general medicine (7.8%). MSD was the third most-costly discipline in 2000/01, with total costs of over A dollars 169 million (9.7% of total inpatient costs that year), behind respiratory medicine (11.6%) and general surgery (11.5%).

Conclusion: Compared to other diseases, MSD consumes a substantial proportion of healthcare resources in Victorian public hospitals. These data have important implications for allocation of healthcare resources, clinical care pathways, and prevention strategies.

Efforts of hospital system wound care teams to reduce hospital acquired pressure ulcers

New reimbursement policies developed by the Centers for Medicare and Medicaid Services (CMS) are revolutionizing the health care landscape in America. The policies focus on clinical quality and patient outcomes. As part of the new policies, certain hospital acquired conditions have been identified by Medicare as "reasonably preventable". Beginning October 1, 2008, Medicare will no longer reimburse hospitals for these conditions developed after admission, pressure ulcers are among the most common of these conditions.^ In this practice-based culminating experience the objective was to provide a practical account of the process of program development, implementation and evaluation in a public health setting. In order to decrease the incidence of pressure ulcers, the program development team of the hospital system developed a comprehensive pressure ulcer prevention program using a "bundled" approach. The pressure ulcer prevention bundle was based on research supported by the Institute for Healthcare Improvement, and addressed key areas of clinical vulnerability for pressure ulcer development. The bundle consisted of clinical processes, policies, forms, and resources designed to proactively identify patients at risk for pressure ulcer development. Each element of the bundle was evaluated to ensure ease of integration into the workflow of nurses and clinical ancillary staff. Continued monitoring of pressure ulcer incidence rates will provide statistical validation of the impact of the prevention bundle. ^

Hospital utilisation among people born in refugee-source countries : an analysis of hospital admissions, Victoria, 1998–2004

Objective: To investigate whether hospital utilisation and health outcomes in Victoria differ between people born in refugee-source countries and those born in Australia. Design and setting: Analysis of a statewide hospital discharge dataset for the 6 financial years from 1 July 1998 to 30 June 2004. Hospital admissions of people born in eight countries for which the majority of entrants to Australia arrived as refugees were included in the analysis. Main outcome measures: Age-standardised rates and rate ratios for: total hospital admissions; emergency admissions; surgical admissions; total days in hospital; discharge at own risk; hospital deaths; admissions due to infectious and parasitic diseases; and admissions due to mental and behavioural disorders. Results: In 2003–04, compared with the Australia-born Victorian population, people born in refugee-source countries had lower rates of surgical admission (rate ratio [RR], 0.85; 95% CI, 0.81–0.88), total days in hospital (RR, 0.74; 95% CI, 0.73–0.75), and admission due to mental and behavioural disorders (RR, 0.70; 95% CI, 0.65–0.76). Over the 6-year period, rates of total days in hospital and rates of admission due to mental and behavioural disorders for people born in refugee-source countries increased towards Australian-born averages, while rates of total admissions, emergency admissions, and admissions due to infectious and parasitic diseases increased above the Australian-born averages. Conclusions: Use of hospital services among people born in refugee-source countries is not higher than that of the Australian-born population and shows a trend towards Australian-born averages. Our findings indicate that the Refugee and Humanitarian Program does not currently place a burden on the Australian hospital system.

Hospital social work in Australia: Emerging trends or more of the same?

Social work in health care has been established for more than 100 years and is one of the largest areas of practice for social workers. Over time, demographic changes and growth in the aging population, increased longevity rates, an explosion in rates of chronic illness together with rapidly increasing cost of health care have created serious challenges for acute hospitals and health social workers. This article reviews the Australian health care system and policies with particular emphasis on the public hospital system. It then examines current hospital social work roles, including the continued role in discharge planning and expanding responsibility for emerging client problems, such as patient complexity, legal, and carer issues. The article concludes with a discussion of evolving issues and challenges facing health social work to ensure that social work remain relevant within this practice context.

Hospitais universitários e fatores ambientais na implementação das politicas de saude e educação : o caso do Hospital Universitário de Santa Maria

Este trabalho monográfico trata de Hospitais Universitários e Fatores Ambientais Relevantes na Implementação das Políticas de Saúde e Educação de Recursos Humanos para a saúde. Primeiramente, busca identificar a evolução das políticas, no Brasil, a partir da VªConferência Nacional de Saúde (1975) até a constitucionalização do Sistema Único de Saúde (1988), deixando evidente as dificuldades de implementação destas políticas no seu nível de orçamento e ação. Levanta, também, as características da instituição Hospital Universitário, desde de sua origem, na década de 60, para atender às necessidades das escolas médicas, até os questionamentos quanto às suas funções sociais nos nossos dias, assim como a forma de sua gestão ao inserir-se no Sistema Único de Saúde. Ainda, caracterizando os Hospitais Universitários como uma organização complexa, busca na literatura da Ciência Administrativa, referências sobre organização, análise ambiental e estratégia no planejamento e gerência. Na análise ambiental, salienta o estudo dos Fatores Ambientais Relevantes, para o melhor desempenho organizacional na implementação adequada das po~íticas. Com este embasamento, faz um estudo de caso do Hospital Universitário de Santa Maria, usando modelo de análise que associa métodos qualitativo e quantitativo com a participação de um grupo interdisciplinar da Universidade Federal de Santa Maria, e programa de processamento de dados - análise estrutural. Com este modelo, levanta os Fatores Ambientais de maior relevância no sistema da organização em estudo. Usa também a técnica da entrevista para atender o objetivo específico de identificar a percepção destes fatores, pelo grupo gerencial da organização hospitalar.

Financial impact of the Medicare prospective payment system on long term acute care hospitals

Objective. Long Term Acute Care Hospitals (LTACs) are subject to Medicare rules because they accept Medicare and Medicaid patients. In October 2002, Medicare changed the LTAC reimbursement formulas, from a cost basis system to a Prospective Payment System (PPS). This study examines whether the PPS has negatively affected the financial performance of the LTAC hospitals in the period following the reimbursement change (2003-2006), as compared to the period prior to the change (1999-2003), and if so, to what extent. This study will also examine whether the PPS has resulted in a decreased average patient length of stay (LOS) in the LTAC hospitals for the period of 2003-2006 as compared to the prior period of 1999-2003, and if so, to what extent. ^ Methods. The study group consists of two large LTAC hospital systems, Kindred Healthcare Inc. and Select Specialty Hospitals of Select Medical Corporation. Financial data and operational indicators were reviewed, tabulated and dichotomized into two groups, covering the two periods: 1999-2002 and 2003-2006. The financial data included net annual revenues, net income, revenue per patient per day and profit margins. It was hypothesized that the profit margins for the LTAC hospitals were reduced because of the new PPS. Operational indicators, such as annual admissions, annual patient days, and average LOS were analyzed. It was hypothesized that LOS for the LTAC hospitals would have decreased. Case mix index, defined as the weighted average of patients’ DRGs for each hospital system, was not available to cast more light on the direction of LOS. ^ Results. This assessment found that the negative financial impacts did not materialize; instead, financial performance improved during the PPS period (2003-2006). The income margin percentage under the PPS increased for Kindred by 24%, and for Select by 77%. Thus, the study’s working hypothesis of reduced income margins for the LTACs under the PPS was contradicted. As to the average patient length of stay, LOS decreased from 34.7 days to 29.4 days for Kindred, and from 30.5 days to 25.3 days for Select. Thus, on the issue of LTAC shorter length of stay, the study’s working hypothesis was confirmed. ^ Conclusion. Overall, there was no negative financial effect on the LTAC hospitals during the period of 2003-2006 following Medicare implementation of the PPS in October 2002. On the contrary, the income margins improved significantly. ^ During the same period, LOS decreased following the implementation of the PPS. This was consistent with the LTAC hospitals’ pursuit of financial incentives.^

Financial impact of the Medicare prospective payment system on long term acute care hospitals

Objective. Long Term Acute Care Hospitals (LTACs) are subject to Medicare rules because they accept Medicare and Medicaid patients. In October 2002, Medicare changed the LTAC reimbursement formulas, from a cost basis system to a Prospective Payment System (PPS). This study examines whether the PPS has negatively affected the financial performance of the LTAC hospitals in the period following the reimbursement change (2003–2006), as compared to the period prior to the change (1999–2003), and if so, to what extent. This study will also examine whether the PPS has resulted in a decreased average patient length of stay (LOS) in the LTAC hospitals for the period of 2003–2006 as compared to the prior period of 1999-2003, and if so, to what extent. ^ Methods. The study group consists of two large LTAC hospital systems, Kindred Healthcare Inc. and Select Specialty Hospitals of Select Medical Corporation. Financial data and operational indicators were reviewed, tabulated and dichotomized into two groups, covering the two periods: 1999–2002 and 2003–2006. The financial data included net annual revenues, net income, revenue per patient per day and profit margins. It was hypothesized that the profit margins for the LTAC hospitals were reduced because of the new PPS. Operational indicators, such as annual admissions, annual patient days, and average LOS were analyzed. It was hypothesized that LOS for the LTAC hospitals would have decreased. Case mix index, defined as the weighted average of patients’ DRGs for each hospital system, was not available to cast more light on the direction of LOS. ^ Results. This assessment found that the negative financial impacts did not materialize; instead, financial performance improved during the PPS period (2003–2006). The income margin percentage under the PPS increased for Kindred by 24%, and for Select by 77%. Thus, the study’s working hypothesis of reduced income margins for the LTACs under the PPS was contradicted. As to the average patient length of stay, LOS decreased from 34.7 days to 29.4 days for Kindred, and from 30.5 days to 25.3 days for Select. Thus, on the issue of LTAC shorter length of stay, the study’s working hypothesis was confirmed. ^ Conclusion. Overall, there was no negative financial effect on the LTAC hospitals during the period of 2003–2006 following Medicare implementation of the PPS in October 2002. On the contrary, the income margins improved significantly. ^ During the same period, LOS decreased following the implementation of the PPS. This was consistent with the LTAC hospitals’ pursuit of financial incentives. ^

Conciliación de medicamentos e identificación de los tipos de discrepancias al ingreso, durante la hospitalización y al alta en pacientes del área de ginecología del Hospital Vicente Corral Moscoso. Cuenca, 2015

La conciliación de medicamentos es la adecuada combinación de conocimientos y evidencias científicas de las reacciones, interacciones y necesidades de los pacientes, constituye en esencial el buen uso de los medicamentos. Objetivo general: Establecer la conciliación de medicamentos e identificar los tipos de discrepancias existentes al ingreso, durante la hospitalización y al alta en las pacientes del área de ginecología del Hospital Vicente Corral Moscoso. Cuenca, durante los meses noviembre – diciembre 2015. Metodología: Se diseñó un estudio descriptivo, con un población de 200 pacientes hospitalizadas en el área de ginecología del Hospital Vicente Corral Moscoso, durante 2 meses del 2015, recolectamos los datos mediante un formulario de dos etapas para la conciliación, a partir de las prescripciones de la historia clínica y entrevista a las pacientes, los que fueron ingresados en el software SPSS 15.0 para su tabulación, análisis, y presentación en tablas. Resultados: Se encontró 161 errores de conciliación y 42 discrepancias justificadas, en promedio 1,87discrepancias no justificadas por paciente. El error de conciliación más frecuente al ingreso corresponde a diferente dosis, vía y frecuencia de administración con un 84,6%, durante la hospitalización y al alta, correspondió a prescripciones incompletas con el 40% y 60,3% respectivamente. Conclusiones: La frecuencia con la que se realiza la conciliación de medicamentos en el Hospital Vicente Corral Moscoso fue del 15%. El 52% de pacientes están expuestos a riesgo por discordancias en las prescripciones, de ellos 43% son errores en la conciliación y un 9 % son discordancias justificadas

Exploring Aboriginal patients’ experiences of cardiac care at a major metropolitan hospital in Melbourne

Objectives: The aim of the present study was to explore Aboriginal patients' lived experiences of cardiac care at a major metropolitan hospital in Melbourne.Methods: The study was a qualitative study involving in-depth interviews with a purposive sample of 10 Aboriginal patients who had been treated in the cardiology unit at the study hospital during 2012-13. A phenomenological approach was used to analyse the data.Results: Eight themes emerged from the data, each concerning various aspects of participants' experiences: 'dislike of hospitals', 'system failures', 'engagement with hospital staff', 'experiences of racism', 'health literacy and information needs', 'self-identifying as Aboriginal', 'family involvement in care' and 'going home and difficulties adapting'. Most participants had positive experiences of the cardiac care, but hospitalisation was often challenging because of a sense of dislocation and disorientation. The stress of hospitalisation was greatly mediated by positive engagements with staff, but at times exacerbated by system failures or negative experiences.Conclusion Cardiac crises are stressful and hospital stays were particularly disorienting for Aboriginal people dislocated from their home land and community.What is known about the topic? Aboriginal people have higher mortality rates due to cardiovascular diseases compared with other Australians. Along with different factors contributing to the life expectancy gap, Aboriginal people also face significant barriers in the use of the healthcare system.What does this paper add? Aboriginal patients' lived experience of cardiac care at a major metropolitan hospital in Melbourne is explored in this paper. Different issues were revealed during their interaction with the hospital staff and the hospital system in conjunction with their cultural aspect of patient care.What are the implications for practitioners? Positive interactions with staff, ongoing support from family and community, culturally appropriate cardiac rehabilitation programs can improve the cardiac care experiences of Aboriginal patients.